Provider Demographics
NPI:1518393743
Name:MILLER, JONATHAN (MA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5025
Mailing Address - Country:US
Mailing Address - Phone:907-374-7776
Mailing Address - Fax:
Practice Address - Street 1:315 5TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5025
Practice Address - Country:US
Practice Address - Phone:907-374-7776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK873101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1596091Medicaid